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Date run -. 2/25/2015 '1:53:56AI SAN X JUIN COUNTY ENVIRONMENTAL HEI`' JH DEPARTMENT Report#5021 <br /> Run by ]�/ tu Pagel <br /> Facility Information as of 2/25/2015 <br /> Record Ser .eria. Facility ID FA0021146 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID : <br /> Owner ID OW0017421 New Owner ID <br /> Owner Name KINGSDOWN INC <br /> Owner DBA KINGSDOWN INC <br /> Owner Address 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206-4983 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-234-1436 <br /> Mailing Address 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021146 10187773 <br /> Facility Name KINGSDOWN INC <br /> Location 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Phone 209-234-1436 x <br /> Mailing Address 1631 INDUSTRIAL DR <br /> STOCKTON, CA 95206 <br /> Care of Ray Gutierrez <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 17732007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0038131 New Account to: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name KINGSDOWN INC (CimleOne) <br /> Account Balance as of 2/25/2015: $290.00 <br /> (Circle One) <br /> Transfer to Active/tri <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0536814 EE00098 -ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0536826 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,an or project specific,PHSIEHD hourly charges associated with thisfacility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. � ? <br /> NL <br /> APPLICANTS SIGNATURE: �IAA T7 L- IZ7J — C " "Date 2— / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date I / <br /> COMMENTS'. <br />